More on When Labelling Patients Causes Patients to Die

Someone on my blog suggested that I check out this post after I just posted about this story yesterday.

To all of you who think “something more should have been done,” what should that “something” have been? She had multiple tests and exams performed for the same complaint – including sonograms which showed no blood clots the day before she died. She was having the same pain in her legs since she was hospitalized the week before. Gold standard test for DVTs is ultrasound. Do we repeat the ultrasound every day? Every hour? What other testing was “necessary”?

TorontoEmerg – think of all the patients you see with back pain requesting narcotic pain medications. Do you order serial MRIs on them to rule out the possibility of cauda equina? Or tumor? If so, what is the medical basis for the testing? If not, why? I’m assuming you don’t. When you miss the one patient who has a tumor and becomes paralyzed, you’ll be harangued because “obviously” the patient had something wrong and you neglected to address it. Yet once you tell the patients that they won’t be receiving any narcotic pain medications, many of the patients in severe pain stand up, curse at you, and storm out of the emergency department.

You say that Ms. Brown was “unable to walk.” The article showed that a nurse saw her standing the same day that she couldn’t walk. How many patients do you see who come to the emergency department and can’t get out of their car when they arrive? That’s a “red flag” that something is wrong. Do you order a million dollar workup on all of them? How many patients do you see who have had dozens of normal CT scans for their chronic abdominal pain? Is that proper medical care? I could go on and on, but you get the point.

The problem is that your post suffers from horrible hindsight bias. You knew the outcome and now you’re bashing the people who treated Ms. Brown because they didn’t have the ability to look into the future to see what would happen.

Yes, the outcome was horrible. Yes, there were miscues and miscommunication. I’m sure that Ms. Brown was “labeled” as someone trying to game the system. Society “labels” every aspect of our lives every day. President Obama is “liberal.” Ron Paul is “crazy.” Pit bulls are “dangerous.” Doctors are “rich.” Baby pandas are “cute.” Doing so doesn’t make us bad, it makes us human. Someone who was articulate and polite to the providers and to the police may have been treated differently. One of my readers said this was the “perfect storm” of events leading up to Ms. Brown’s death.

To say that Ms. Brown didn’t receive proper care or that her complaints were ignored is just wrong. I’m betting if you ordered all the testing you think Ms. Brown should have received on all of the patients who walked through the doors at your emergency department, *you’d* be the one being ridiculed.

I appreciate WhiteCoat taking the time to post such a lengthy reply. He fully explicates many of his points on his blog. I won’t editorialize much here, because I think his perspective is important to how we discuss cases like Anna Brown. I don’t share his point of view for a number of reasons, but I do agree with him that labelling people makes us human. The trouble starts, for me at least, when we allow our interior — and often unrealized — biases to influence our care.

In my view — and I’ve read WhiteCoat’s blog posts on this — the problem is not really the ER, but rather the police. There is no excuse for the woman to end up on the concrete floor, unattended and alone for 90 minutes. ANYONE who says she can’t walk and is in obvious distress should be monitored continually, assuming she has to remain in custody at all, which is very very dubious.

The doctor who released her as fit for custody also made an iffy choice. Surely, s/he didn’t mean “fit to be left alone on a jail cell floor.” But if so, s/he should have made that abundantly clear.